Retainer, Concierge and Boutique Medicine are Not the Same Thing

Health care is in crisis. Reimbursements from insurance companies continue to dwindle, while the expenses of running an office continue to rise.  Looming cuts in Medicare are only weeks away, and many physicians may stop taking Medicare.  If these cuts go into affect, it is possible that primary care physicians could lose up to 50% of their salary.  Just recently CNN reported that some doctors are going bankrupt.

How to fix our health care system is an ongoing debate, but not surprisingly, many physicians have decided not to wait for the government to solve this problem and have taken matters into their own hands. One solution is to simply stop taking insurance altogether.  “Cash only” doctors are now commonplace in many major metropolitan areas.  Another solution is charging a regular, out of pocket fee (usually) in addition to what insurance will pay for treatment.  A version of this model that is becoming popular is called retainer medicine.  Sometimes, retainer medicine is referred to a “boutique” or “concierge” even by physicians and others involved in health care (as evidenced by this article in the AMA News, which prompted me to post on this topic).

However, “retainer”, “concierge” and “boutique” are not the same thing. Names are important, and the terms “concierge” and “boutique” tend to have negative connotations. Thus, it is important to describe the differences.

In a retainer model, patients pay a fee (not covered by insurance) to be part of a physician’s practice.  This is similar to clients paying a retainer fee to hire a specific lawyer.  With reimbursements from insurance companies being so low, the only way an insurance based physician can increase revenues is to increase the volume of patients they see.  Unfortunately, when physicians increase the number of patients they see, it leads to rushed patient visits, long waits in the waiting room, and decreased access to physicians including difficulty in getting appointments or responses phone call messages.  By accepting a retainer fee, the physician no longer needs to rely on insurance revenue alone, and in fact can decrease the amount of patients he or she sees on a regular basis. This allows for increased access (usually same day or next day appointments and 24/7 phone access) and longer appointment times (usually 30-60 minutes) for patients willing to pay a retainer fee.  The typical insurance based primary care physician has about 2500-3000 patients in their practice, and sees about 25 patients a day.  The typical retainer physician has about 500 patients and sees only a handful of patients each day.  Retainer fees and the amount of access patients get for what they pay vary widely, but the average retainer fee is about $1500 per year. 

Some have argued that retainer medicine is unethical because not everyone can afford $1500 a year.  First, the typical retainer fee amounts to about $4 a day, which is what many Americans pay (or more) for a Starbucks coffee. Secondly, one could also argue that it is also unethical for insurance based physicians to see complex patients in brief visits and/or not being able to see them in a timely fashion due to lack of access. 

Concierge medicine is somewhat different, and in my opinion, should not be used synonymously with retainer medicine. 

According to Wikipedia;

“A concierge is an employee who either works in shifts within, or lives on the premises of an apartment building or a hotel and serves guests with duties similar to those of a butler. The term "concierge" evolved from the French Comte Des Cierges, The Keeper of the Candles, who tended to visiting nobles in castles of the medieval era.”

Just like the concierge at a hotel, who can get you good seats at a ticketed event, a reservation at a popular restaurant, or even run an errand; a concierge physician can get you timely appointments with the best specialists, usually doing the scheduling themselves.  Many concierge physicians will even accompany patients to procedures or diagnostics tests, and some will even make house calls. Though some retainer practice physicians may perform concierge services (usually the ones charging well over the usual $1500 fee), the terms are not the same.  Many retainer physicians will assist in coordinating specialist appointments, but this is as far as they go. In fact, some “cash only” physicians perform concierge services to attract more patients, and some doctors (even insurances based physicians) will charge an extra-fee for some concierge services, such as a house call.

Boutique medicine is also completely different. Again, from Wikipedia:

“A boutique is a small shopping outlet, especially one that specializes in elite and fashionable items such as clothing and jewelry. It can also refer to a specialised firm such as a boutique investment bank or boutique law firm. In the strictest sense of the word, boutiques would be one-of-a-kind but more generally speaking, some chains can be referred to as boutiques if they specialize in particularly stylish offerings.”

I think the key words in this definition are “specilalized” “stylish” and “elite.” The first word is something commonplace in medicine, but the later two words are something usually not associated with medical practice. “Luxury” is also implied in the word “botique.”  Thus, in my opinion, a boutique doctor is one that specializes in unique, often luxurious services, that are not offered by others and which will therefore cost a little extra.  These services include, but are not limited to, cosmetic procedures (botox, laser hair removal), medical spa services, comprehensive screenings (i.e. body scans), and herbs or supplements.  Though both retainer and concierge physicians may provide boutique services, this is generally not the norm.  In fact, many insurance based primary care physicians have started to add these services as a way of keeping their practice running. (Ethics could be questioned here as well).

I am not arguing that retainer medicine is the solution for all of our nation’s health care woes. It certainly is not.  However, given that it solves some of the issues with 3^rd party payors, is a model that continues to grow, and patients and providers enrolled seem to be very satisfied; it is something that deserves attention.  Another model that is garnering some attention is direct access primary care.  In this model, patients pay a monthly fee (usually about $70/month) and receive enhanced access and communication as well as primary care and urgent care services. Though the cost is slightly less ($1500/yr vs. $840/yr) and access to your personal may not be 24/7, this is a similar model to the retainer concept. (Proponents have called this retainer medicine for the masses).

Thus, using terms “concierge” and “boutique” that have connotations of elitism, luxury and unnecessary care synonymously with retainer medicine discredits a potentially viable health care model for many Americans.  I would request that physicians, policy makers and journalists no longer use these terms as if they were the same. 

Insurance Free Medicine

I never thought I would be in academic medicine for so long. When I was hired about 12 year ago, I figured I would stay in academics for a few years and then join a private practice Internal Medicine group. Now, I can't even fathom that idea. One of the reasons I have stayed at my institution for so long is that I love teaching and the academic environment. However, a second reason is that the "real world" for primary care medicine is a scary one. As a salaried employee in a large practice, I am somewhat sheltered from the harsh realities of running a business in the current health care environment. Yet, I hear horror stories from my colleagues in the community that are struggling to survive. With reimbursement rates from insurances so low, and administrative burdens so high, many older physicians have retired and younger physicians have adopted new models of delivering care. These have various names such as "concierge medicine" or "boutique practices".

Though I have no intention of leaving any time soon, I know that (assuming there are not major changes via health care reform) the current model of a small group of primary care physicians who accept insurance is simply not sustainable. Yet, I have a hard time imagining myself practicing in one of these new models, or even attracting patients to my practice. Retainer medicine is one model, where primary care physicians are able to see a much smaller panel size (and thus increase access) by charging patients an annual fee, which ranges from hundreds to thousands of dollars. Though the model makes financial sense, the word "retainer" sounds too legalese for me and likely not easily understood by the lay public. I would prefer something like "membership fee" similar to something would pay to join a club. However, "membership medicine" or "club medicine" just doesn't seem to have a good ring.

"Boutique" practices often use a retainer model, but boutique can also refer to primary care physicians who charge for extra services such as laser hair removal or botox injections. There are many primary care physicians who still take insurance that have started using these kind of practices or have found other ways to meet their bottom line, such as selling nutritional supplements. Though there is no question that the public has a demand for these services, providing them for a fee as a primary care physician seems to carry some conflict of interest, since none of these services show any benefit in overall health. "Concierge medicine" is another term used with retainer models and boutique practices. This implies some sort of preferential treatment, but also usually is associated with "executive physicals" and a battery of unnecessary testing and high technology that again provides little in the way of proven health benefits.

Some physicians have continued to practice normally, but simply do not accept insurance. They have figured out that they can sustain a primary care practice if they simply refuse to accept the substantially reduced rates that insurance companies give them. These are often referred to as cash only practices. Yet, the term "cash only" seems to imply (at least to me) something shady or under the table. In addition, most patients who see cash only physicians, pay for these services using a credit card, making the name somewhat illogical.

However, the reason that all these new models of medicine exist boils down to one single reason: health insurance. Rates from insurance companies are so low, that the only way a primary care physician can make ends meet is to increase volume to the point that both access and care delivery suffer substantially. In addition, the administrative headaches which include fighting to get tests/medicines covered and arguing over claims once submitted, make the practice of medicine less than enjoyable. The often quoted study (that I co-authored) showing that only 2% of medical students are interested in primary care internal medicine, is often used to support the argument that primary care physicians need to be paid more. While the need to substantially reduce the growing income discrepancy between primary care physicians and specialists is critically important, the study actually showed that educational experience, nature of patient care and lifestyle were the primary factors influencing career choice, not income. This was regardless of students' medical school debt. In other words, it was more about the hassles of primary care medicine and less about the how much money they would make, that led students away from careers in primary care.

Thus, I think a term that I would like to propose for use in further discussions of newer ways of practicing primary care (in blogs, media, etc.) is "insurance free medicine." In my opinion, the term "insurance free medicine" captures the essence of the newer models of primary care. Patients have certainly seen their premiums and deductibles increase and can probably relate quite well to reasons why a doctor would not accept insurance. Insurance free primary care practices could certainly adopt retainer membership fees and promote improved access, but eliminating terms like "boutique," "concierge," and "cash only" might help eliminate the notion that primary medical care without insurance is somehow tainted or only for the super-wealthy. In a previous post on KevinMD, I discussed that without substantial changes, primary care will soon go the way of psychiatry in that patients who use their insurance to see a psychiatrist get one kind of care (very brief visits, mostly management by a non-physician) and those who pay their psychiatrist out-of-pocket get the kind of care that we see in TV and the movies. With a more frequent use of the term "insurance free medicine," patients might start realizing that if they continue to pay their primary physician using their health care insurance, they should expect even briefer visits, longer waits to get in, seeing non-physicians, and greater delays getting a return phone call or results back.

Though I have no immediate plans to leave the world of academia any time soon, I could certainly see starting an insurance-free practice if I ever did.